EL ARTÍCULO EDITORIAL

Adjunct therapies can augment the healing process for pressure ulcers in any phase of wound healing, as long as the standard of care is implemented concomitantly. For example, using electrical stimulation on a pressure ulcer in the absence of off-loading will do little for creating a positive outcome for the patient.

Below is a description of adjunct therapies for the reader to explore and to make the appropriate referral to a clinician trained in their use, but does not necessarily constitute a "recommendation" by the work group.

Refer to recommendations discussed at the end of the annotation. Note: there is little data comparing the use of one adjunct therapy to another.

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www.icsi.org Biophysical agents

Biophysical agents or modalities such as electrical stimulation; induced electrical stimulation; photo therapy, i.e., infrared and ultraviolet; negative pressure wound therapy; hyperbaric oxygen; and contact, non-thermal ultrasound all add some form of energy to the wound bed to help drive the healing process forward, especially in the compromised tissues of patients who tend to get pressure ulcers.

Electrical stimulation for wound healing is defined as the use of a capacitive coupled electrical current to transfer energy to a wound. The type of electricity that is transferred to the target tissue is controlled by the electrical source. A physical therapist will have the knowledge required to set the polarity, amplitude and voltage, amperage, wave forms, frequency and duty cycle appropriate for the state of each wound and patient. Electrical stimulation to the wound bed uses galvanotaxis to attract cells of repair to the site. There is a significant body of research that demonstrates that polarity influences healing in different ways at different phases (Sussman, 2007 [R]). Electrical stimulation also improves local blood flow and oxygen delivery, has antibacterial effects, helps with debridement and thrombolysis, and decreases pain. Contraindications are malignancy, an electronic implant or metal implant. Consider the use of direct contact (capacitative) electrical stimulation in the management of recalcitrant category/stage II, as well as category/stage III and IV pressure ulcers to facilitate wound healing.

Induced electrical stimulation is technology that induces the flow of electrons in the tissue rather than directly applying electricity. These technologies are pulsed radio frequency stimulation, pulsed electromagnetic fields, and pulsed short-wave diathermy. All of these are forms of diathermy, but for wound healing are set up, and applied, to be non-thermal. All class III diathermy non-thermal medical devices licensed by the Federal Drug Administration induce electrical current in the tissues, and as such, will have the same clinical effects, indications and contraindications as direct electrical stimula-tion (Sussman, 2007 [R]).

Hyperbaric oxygen therapy is the application of oxygen to the host's tissues above atmospheric pressure.

Hyperbaric oxygen therapy can increase oxygen diffusion to a wound and the hemoglobin's ability to carry oxygen, therefore meeting the increased demand of oxygen for cellular metabolism. It may also eliminate oxygen-free radicals; reduce bacterial growth; increase the ability for white blood cells to kill bacteria; and increase angiogenesis, collagen synthesis, granulation tissue formation, epithelialization, and wound contraction. Systemic hyperbaric oxygen is administered by a Certified Hyperbaric Regis-tered Nurse (CHRN) or a Certified Hyperbaric Technologist (CHT). Hyperbaric oxygen is generally not the first adjunct therapy considered since wound ischemia is due to pressure that should be eliminated through support surfaces, splinting and positioning. If off-loading measures are adequate, the wound should get enough perfusion, as long as no arterial insufficiency is present. Again, if a pressure ulcer is present distal to the knee, check for adequate blood flow (Meyers, 2007 [R]).

Negative pressure wound therapy devices apply negative pressure, or suction, to the wound bed. The negative pressure applied to the wound bed creates three main physical effects: 1) tension on tissues that stimulate mitotic division, 2) increased local blood flow in the capillary bed, and 3) evacuation of excess interstitial fluids. The subsequent physiological effects to the wound bed are exudate control, increased granulation tissue formation, reduced wound and periwound edema, increased wound contraction, and increased epithelialization (Meyers, 2007 [R]; Gupta, 2004 [M]). This technology should be applied by a clinician (registered nurse, physical therapist, physician, podiatrist, etc.) trained in its indications, contraindications, precautions and different methods of application. It is a skilled application, with risk if not done properly, and it should also be monitored by clinician for any adverse outcomes or events, specifically frank bleeding from a named vessel or organ.

(European Pressure Ulcer Advisory Panel, 2009 [R]) Return to Algorithm Return to Table of Contents

www.icsi.org The Federal Drug Administration has received reports of serious complications, including death, associated with the use of negative pressure wound therapy systems. The Federal Drug Administration advises health care professionals to carefully select patients for negative pressure wound therapy after reviewing the most recent device labeling and instructions. Patients should be monitored frequently in an appropriate care setting by a trained practitioner. Practitioners should be vigilant for potentially life-threatening complications, such as bleeding, and be prepared to take prompt action if they occur. To see full alert, refer to the Federal Drug Administration alert (02/24/2011) addressing negative pressure wound therapy at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm. In addition, on February 28, 2011, the Food and Drug Administration issued a statement indicating the safety and effectiveness of negative pressure wound therapy systems in newborns, infants and children has not been established. To see the full alert, refer to the Food and Drug Administration alert (02/28/2011) http://www.

fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm190704.htm.

Non-contact, non-thermal ultrasound is a mechanical vibration transmitted at a frequency beyond the upper limit of human hearing (Ennis, 2005 [A]). These sound waves are transmitted in human tissues and cause vibration within them. That vibration causes acoustic cavitation and acoustic streaming, which ultimately create waves of pressure on the cell membrane and fluid movement around the membrane, stimulating all the structures on the cell membrane, including receptor sites. Studies have shown that these effects create increased membrane permeability and cell activity. The acoustic pressure is not tolerated by the more rigid cell walls of bacteria. Ultrasound can be modulated for thermal effects, non-thermal effects, diagnostic reading, and excision as in debridement. It is not in the scope of this protocol to discuss the diagnostic or debriding ultrasound devices. If set for thermal effects, using MHz ultrasound, a chronic wound can be returned to acute wound healing. Non-thermal ultrasound, most commonly administered as kHz ultrasound, can stimulate the cells of repair to do more of what they are already programmed to do: be bacteriocidal, and stimulate capillary growth in the wound bed, depending on the kind of kHz device selected. Physical therapists are trained in ultrasound application and variation, and registered nurses can apply ultrasound that is already set for wound healing by the device. When determining who will administer this modality, check your state's scope of practice acts.

Phototherapy: Photobiologists are studying the effects of different wavelengths of light on human tissues. When focused and intensified, as in laser form, doses of light can quickly and painlessly be administered to patients. The two most studied phototherapies are infrared and ultraviolet. Ultraviolet aides in wound healing because it is bacteriocidal, including methicillin-resistant staphylococcus aureus, vancomycin-resistant enterococci, and pseudomonas (Conner-Kerr, 1999 [NA]; Conner-Kerr, 1998 [NA]). Infared has two main effects: the release of nitric oxide, a known vasodilator and angiogenic stimulator; and increasing cellular activity of all cells. The infrared rays are absorbed by cell mito-chondria and converted into ATP, just like photosynthesis, which increases DNA and RNA synthesis, protein production in ribosomes, and all other cellular functions of a cell. This increases the cycle of mitosis and cell proliferation. Historically, physical therapists have had the class II and class III laser phototherapy devices. Please check the practice acts in your state.

Biological applications

These are products that donate physiological constituents in wound healing to the wound bed. They can donate extra cellular matrices, cells of repair, cellular communicators, and growth factors. They take the form of gels and sheets placed in the wound bed that is prepared: free of necrosis and bacterial bioburden. These products are an attempt to modulate chronic wound physiology, moving it forward into a more normal rate of repair by providing the wound with resources it otherwise did not have or is slow to recruit. Categories are platelet gels, platelet-derived growth factor therapy, biological skin substitutes, and extracellular matrix sheets. For these products, it is recommended that you refer the patient to a wound-focused physician or clinician, who will be able to help select the appropriate product.

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Pain Management

Pressure ulcers can be extremely painful, and it is important to assess every patient with a pressure ulcer for pain (Rastinehad, 2006 [D]). Wound pain may be decreased by maintaining a moist wound bed or by using non-adherent dressings. Some dressings, such as hydrogels or foams, may cause less pain and require less frequent dressing changes. Assessment of the pain component of a wound should occur at regular intervals, such as on admission, with reassessments, with routine vital signs, with changes in activity level, with dressing changes, and after other painful interventions (Szor, 1999 [D]).

Pharmacological and non-pharmacological pain relief measures should be considered to treat the pain associated with a pressure ulcer or with the interventions needed to treat the ulcer. Consider premedication for effective pain management prior to implementing any wound care, especially with debridement. Use of analgesics and adjunctive therapies are important interventions to consider in alleviating the painful experience. Two small studies indicate topical opioids may be a consideration for reducing pressure ulcer pain (Flock, 2003 [A]; Twillman, 1999 [D]. Non-pharmacologic interventions could include repositioning, positioning off the pressure ulcer, using effective safe-handling devices such as lift devices or transfer sheets, use of pressure redistribution devices, relaxation techniques, guided imagery, music therapy, and distraction (Rastinehad, 2006 [D]).

Nutrition

Specific nutrient goals for treatment of pressure ulcer

Treatment plans for the nutritional needs of persons with pressure ulcers include:

1. Fluid needs are calculated, taking into account the patient's overall hydration status.

General Formula, 1mL per kcal of calories consumed or 30 mL/kg of body weight with 1500 mL minimum unless medically indicated diseases present, such as renal or congestive heart failure (American Society for Parenteral and Enteral Nutrition, 2007 [R]; Dorner 2004 [R]).

2. Protein recommendations vary from 1-2 g/kg/day. Clinical judgment will be needed to estimate protein needs, which may vary depending on the patient's medical condition. Consideration should be given to include use of evening protein supplement (European Pressure Ulcer Advisory Panel, 2009 [R]; American Society for Parenteral and Enteral Nutrition, 2007 [R]; Dorner, 2004 [R]).

Protein requirements may vary by stage of pressure ulcer, from 1.25-1.5 g/kg/day for stages I-IV and 1.5-2 g/kg/day with those patients with larger stage III or IV or for those with multiple pressure ulcers (American Society for Parenteral and Enteral Nutrition, 2007 [R]). The amount of wound exudate, which contains significant amounts of protein, may also affect the amount of protein needed (Doley, 2010 [R]).

3. Caloric requirements are based on the patient's individual nutritional goal. There are various methods to determine include Harris Benedict and use of 30-35 kcals/kg of body weight. Caloric needs may need to be decreased or increased based on individual needs and should be reevaluated based on patient's weight history, as well as current weights (American Society for Parenteral and Enteral Nutrition, 2007 [R]; Dorner, 2004 [R]).

4. Vitamin C requirements should be met with addition of daily citrus fruits. If found to be deficient or suspected of being deficient based on dietary history, short-term daily supplementation of 50-100 mg of Vitamin C is recommended (Dorner, 2004 [R]).

5. Zinc supplementation recommendations are variable. When possible, lab assay should be taken to evaluate zinc deficiency. Zinc deficiency may be the result of draining wounds, increase in gastrointestinal losses or poor dietary intake. When deficiency is indicated through lab assays, recommendations are for 40 mg of elemental zinc (220 mg of zinc sulfate) daily for two to four weeks and labs redrawn (Dorner, 2004 [R]).

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www.icsi.org Therapeutic vitamin and mineral supplement

Daily administration may be considered if poor oral intake or deficiencies are suspected based on patient history or lab assays. This supplementation may contain recommended vitamin C dosage (Dorner, 2004 [R]).

Biochemical data

Serum albumin and prealbumin may be useful to establish overall health. However the results are also reflective of other disease states such as liver disease hydration or renal disease. This needs to be taken into account as the levels may not correlate to nutritional status (Dorner, 2009 [R]; European Pressure Ulcer Advisory Panel, 2009 [R]).

Arginine and glutamine

Supplemental use of arginine and glutamine is controversial and more studies need to be undertaken; at this time supplementations are not recommended (American Dietetic Association Nutrition Care Manual, 2009 [R]; Dorner, 2009 [R]; Dorner, 2004 [R]).

Vitamin A

Excessive vitamin A supplementation can lead to an exacerbated inflammatory response. Also, in patients with chronic renal failure, vitamin A supplementation is frequently contraindicated as vitamin A levels are typically high in this population, and there is an increased risk of hypercalcemia. Patients with fat malabsorp-tion may require a water-miscible form of vitamin A. Discuss supplementamalabsorp-tion of vitamin A with a registered dietitian or physician to address correct dosage (American Society for Parenteral and Enteral Nutrition, 2007 [R]). Therapeutic vitamin and mineral supplement may provide vitamin A at daily requirement needs.